What do GPs feel about sickness certification? A systematic search and narrative review

Suitability of issuing sickness certifications in remote consultations during the COVID-19 pandemic. A mixed method study of GPs' experiences

OBJECTIVE

To explore Norwegian GPs' experiences with and perceived suitability of issuing sickness certifications in remote consultations during the COVID-19 pandemic.

DESIGN

We used a mixed methods research design. An online survey with 301 respondents was combined with qualitative interviews with ten GPs.

SETTING

Norwegian general practice.

RESULTS

Most GPs agreed it was difficult to assess a patient's ability to work without physical attendance for a first-time certification in remote consultations. However, extending a certification was considered less problematic. If physical examinations were required, the GPs would ask the patient to come to the office. The most suitable diagnoses for remote certification were respiratory infections and COVID-19-related diagnoses, as well as known chronic and long-term diseases. The GPs emphasized the importance of knowing both the patient and the medical problem. The GP-patient relationship could be affected by remote consultations, and there were mixed views on the impact. Many GPs found it easier to deny a request for a sickness certification in remote consultations. The GPs expressed concern about the societal costs and an increased number of certifications if remote consultations were too easily accessible. The study was conducted during the COVID-19 pandemic, and the findings should be interpreted in that context.

CONCLUSIONS

Our study shows that issuing sickness certifications in remote consultations were viewed to be suitable for COVID-19 related problems, for patients the GP has met before, for the follow-up of known medical problems, and the extension of sickness certifications. Not meeting the patient face-to-face may affect the GP-patient relationship as well as make the GPs' dual role more challenging.

Patients' experiences with receiving sick leave certificates via remote consultations in Norway during the COVID-19 pandemic: a nationwide online survey

OBJECTIVES

To explore patients' experiences with receiving sick leave certificates via remote consultations during the COVID-19 pandemic and investigate whether there were differences among the types of remote consultation (telephone, video or text).

DESIGN

A nationwide online patient survey consisting of quantitative data supplemented by qualitative opinions conducted in Norway.

SETTING

Primary care.

PARTICIPANTS

Patients who received a sick leave certificate via remote consultation in the period from 16 November to 15 December 2020.

RESULTS

Of the 5429 respondents, 3233 (59.6%) received a sick leave certificate via telephone consultation, 657 (12.1%) via video consultation and 1539 (28.3%) via text-based e-consultation. Most respondents (76.8%) were satisfied. Only 10% of the respondents thought that the doctor would have obtained more information through an office appointment. The majority of the respondents (59.6%) found that they had as much time to explain the problem as at an office appointment. Some patients also thought that it was easier to formulate the problem via a remote consultation (18.2%) and agree with the doctor on the sick leave (10.3%).The users of text-based e-consultations were the most satisfied (79.3%, p<0.001) compared with those using telephone or video consultations. Among users of text-based e-consultations, there was a higher proportion of patients who thought that they had more time to explain the problem compared with an office appointment (p<0.001), it was easier to explain the problem (p<0.001) and agree with the doctor (p<0.001). Most respondents would use the same type of remote consultation if they were to contact the general practitioner (GP) for the same problem, with the highest proportion among the users of video consultations (62.1%, p<0.001).

CONCLUSIONS

Patients were satisfied with communicating and receiving sick leave certificates via remote consultations. Future studies should investigate patients' and GPs' use and experiences in a postpandemic setting.

General practitioners' stay-at-work practices in patients with musculoskeletal disorders: using Intervention Mapping to develop a training program

OBJECTIVES

To describe current stay-at-work practices among Danish general practitioners (GPs) in relation to patients with musculoskeletal disorders, to identify potential avenues for improvement, and to suggest a training program for the GPs.

DESIGN AND SETTING

We followed the principles of Intervention Mapping. Data were collected by means of literature searches, focus group interviews with GPs, and interaction with stakeholder representatives from the Danish labour market.

RESULTS

GPs' current stay-at-work practices were influenced by systemic, organisational, and legislative factors, and by personal determinants, including knowledge and skills relating to stay-at-work principles and musculoskeletal disorders, recognition of the patient's risk of long-term work disability, their role as a GP, and expectations of interactions with other stay-at-work stakeholders. GPs described themselves as important partners and responsible for the diagnostic and holistic assessments of the patient but placed themselves on the side line relying on the patient or workplace stakeholders to act. Their practices are influenced both by patients, employers, and by other stakeholders. We propose a training course for GPs that incorporate both concrete tools and behaviour change techniques.

CONCLUSIONS

We have identified varied perspectives on the roles and responsibilities of GPs, as well as legislative and organisational barriers, and proposed a training program. Not all barriers identified can be addressed by a training course, and some questions are left unanswered, among others - who are best suited to help patients staying at work?

Factors associated with general practitioners' contacts with sick-listed patients' employers: A Swedish nationwide questionnaire study

Background: General practitioners' (GP) contacts with sick-listed patients' employers have been shown to be of importance for return to work. This study aimed to explore GPs' contacts with sick-listed patients' employers and factors associated with such contacts. Methods: In this cross-sectional study, 4228 GPs responded to a nationwide questionnaire about sickness certification (SC) practices. Outcomes of interest were participation in stakeholder meetings, having other contacts with employers, and satisfaction with employer contacts. Logistic regression models were used to investigate associations with factors related to the GP and the GP's workplace. Results: Among GPs, 34.8% participated in stakeholder meetings and 15.1% had other employer contacts; 39.4% had any or both of these contacts. Of GPs who had contacts with patients' employers, 65.8% were satisfied with the contacts. GPs regularly collaborating with rehabilitation coordinators had the strongest adjusted odds ratio (OR) for participating in stakeholder meetings, OR 2.72 (95% confidence interval (CI) 2.24-3.31), and having other contacts with employers, OR 3.85 (95% CI 2.85-5.21). Other factors positively associated with employer contacts were being a specialist, collaborating with other health professionals, finding employer contacts valuable, and having a joint SC routine/policy at the clinic. GPs who did not find SC problematic, had managerial support, or had enough resources for SC tasks were more likely to be satisfied with their employer contacts. Conclusions: Both physician characteristics and organizational factors had importance for GPs' contacts with sick-listed patients' employers. The findings imply that GPs' collaboration with patients' employers may be improved by interventions targeting both individual and organizational factors.

Interventions regarding physicians' sickness certification practice - a systematic literature review with meta-analyses

OBJECTIVE

A variety of interventions aiming to influence physicians' sickness certification practice have been conducted, most are, however, not evaluated scientifically. The aim of this systematic literature review was to obtain updated knowledge about interventions regarding physicians' sickness certification practice and to summarize their possible effects, in terms of sickness absence (SA) or return to work (RTW) among patients.

METHODS

We searched PubMed and Web of Science up through 15 June 2020 and selected peer-reviewed studies that reported effects of controlled interventions that aimed to improve physicians' sickness certification practice and used SA or RTW among patients as outcome measures. Meta-analyses were conducted using random-effect models.

RESULTS

Of the 1399 identified publications, 12 studies covering 9 interventions were assessed as relevant and included in the review. Most (70%) were from the Netherlands, two had a controlled, and seven a randomized controlled study design. All interventions included some type of training of physicians, and two interventions also included IT-support. Regarding the outcomes of SA/RTW, 30 different effect measures were used. In the meta-analyses, no statistically significant effect in favor of the interventions was observed for having any RTW (i.e. first, partial, or full) nor full RTW.

CONCLUSIONS

The individual studies showed that physicians' sickness certification practice might be influenced by interventions in both the intended and non-intended direction, however, no statistically significant effect was indicated by the meta-analysis. The included studies varied considerably concerning intervention content and effect measures.KEY POINTSThe knowledge is very limited regarding the content of interventions directed to physician's sickness certification practiceThe identified interventions included some type of training of physicians, and some of them also included IT-support for physiciansThere was a great heterogeneity among the interventions concerning effect measures used regarding return to work among patientsThe individual studies showed that physicians' sickness certification practice might be influenced by interventions in both intended and non-intended directions, however, the overall meta-analysis did not indicate an effect.

Physician's use of sickness certification guidelines: a nationwide survey of 13 750 physicians in different types of clinics in Sweden

OBJECTIVES

To explore physicians' experiences of using the national sickness certification guidelines introduced in 2007 and the types of information they used, in general and in different types of clinics.

DESIGN

Cross-sectional survey.

SETTING

Most physicians working in Sweden in 2017.

PARTICIPANTS

A questionnaire was sent to 34 718 physicians; 54% responded. Analyses were based on answers from the 13 750 physicians who had sick leave cases.

OUTCOME MEASURES

To what extent the guidelines were used and what type of information from them that was used.

RESULTS

Ten years after the sickness certification guidelines were introduced in Sweden, half of the physicians used them at least once a month. About 40% of physicians in primary healthcare and occupational health services used the guidelines every week. The type of information used varied; 53% used recommendations about duration and 29% about degree of sick leave. Using information about function and activity/work capacity, respectively, was more common within primary healthcare (37% and 38%), psychiatry (42% and 42%), and occupational health services (35% and 41%), and less common in surgery and orthopaedic clinics (12% and 12%) who more often used information about duration (48% and 53%). Moreover, 10% stated that the guidelines were very, and 24% fairly problematic to apply. Half (47%) stated that the guidelines facilitated their contacts with patients and 29% that they improved quality in their management of sick leave cases. More non-specialists, compared with specialists, found that the guidelines facilitated contacts with patients (OR 3.28, 95% CI 3.04 to 3.55).

CONCLUSIONS

The majority of the physicians used the sickness certification guidelines, although this varied with type of clinic. Half stated that the guidelines facilitated patient contacts. Yet, some found it problematic to apply the guidelines. Further development of the guidelines is warranted as well as more knowledge about them among physicians.

The Doctor as Parent, Partner, Provider… or Comrade? Distribution of Power in Past and Present Models of the Doctor-Patient Relationship

The commonly occurring metaphors and models of the doctor–patient relationship can be divided into three clusters, depending on what distribution of power they represent: in the paternalist cluster, power resides with the physician; in the consumer model, power resides with the patient; in the partnership model, power is distributed equally between doctor and patient. Often, this tripartite division is accepted as an exhaustive typology of doctor–patient relationships. The main objective of this paper is to challenge this idea by introducing a fourth possibility and distribution of power, namely, the distribution in which power resides with neither doctor nor patient. This equality in powerlessness—the hallmark of “the age of bureaucratic parsimony”—is the point of departure for a qualitatively new doctor–patient relationship, which is best described in terms of solidarity between comrades. This paper specifies the characteristics of this specific type of solidarity and illustrates it with a case study of how Swedish doctors and patients interrelate in the sickness certification practice.

NICE public health guidance update

This article highlights recent guidance from the National Institute for Health and Care Excellence (NICE). It highlights the organization's response to the COVID-19 pandemic and then provides a spotlight on workplace health in the context of long-term sickness absence and capability to work. It discusses some of the actions that need to be taken by a range of stakeholders in order to implement NICE guidance in this area and aid employees in ensuring good workplace health. The NICE guidance on workplace health, discussed in this article, predates the current pandemic. Comment is made specifically on fitness for work assessments, where the COVID-19 pandemic has posed a range of unique clinical challenges.

Primary care physicians' concerned voices on sickness certification after a period of reorganization. Focus group interviews in Sweden

Objective: This study explored the views of primary health care (PHC) physicians on sickness certification after reforms in 2005 prompted by the Swedish government to increase the quality and decrease the inequalities, and costs of sickness certification.Design: Qualitative design with focus group interviews. Data were analysed using qualitative content analysis.Setting: Urban and rural PHC centres in Region Västra Götaland, Sweden.Subjects: GPs, interns, GP trainees and locums working in PHC centres 2015. Six focus group interviews with 28 physicians were performed.Main outcome measures: Experiences and reflections about the sickness certification system.Results: The latent content was formulated in a theme: 'The physicians perceived the sickness certification process as emotive and a challenge to master with differing demands and expectations from authorities, management and patients'. Sickness certification could be easy in clear-cut situations or difficult when other factors besides the pure medical were ruling the decisions. The physicians' coping strategies for the task included both active measures (cooperation with health care staff and social insurance officers) and passive adaptation (giving in or not caring too much) to the circumstances. Proposals for the future were to transfer lengthy sickness certifications and rehabilitation to specialized teams and increase cooperation with rehabilitation coordinators and social insurance officers.Conclusions: Political decisions on laws and regulations for sickness certification impacted the primary health care making the physicians' work difficult and burdensome. Their views and suggestions should be carefully considered in future organization of primary care. KEY POINTSIn 2005 Swedish government introduced reforms to decrease the inequalities and costs of sickness certification and facilitate the physicians' work. Focus group interviews with Swedish primary care physicians revealed that sickness certification was challenging due to differing demands from authorities, management and patients.Coping strategies for the sick-listing task included both active measures and passive adaptation to the circumstances.A proposal for future better working conditions for physicians was to transfer lengthy sickness certifications and rehabilitation to specialized teams.

Assessing work capacity - reviewing the what and how of physicians' clinical practice

Background

Although a main task in the sickness certification process, physicians’ clinical practice when assessing work capacity has not been thoroughly described. Increased knowledge on the matter is needed to better understand and support the certification process. In this review, we aimed to synthesise existing qualitative evidence to provide a clearer description of the assessment of work capacity as practiced by physicians.

Method

Seven electronic databases were searched systematically for qualitative studies examining what and how physicians do when they assess work capacity. Data was analysed and integrated using thematic synthesis.

Results

Twelve articles were included. Results show that physicians seek to form a knowledge base including understanding the condition, the patient and the patient’s workplace. They consider both medical and non-medical aspects to affect work capacity. To acquire and process the information they use various skills, methods and resources. Medical competence is an important basis, but not enough. Time, trust, intuition and reasoning are also used to assess the patient’s claims and to translate the findings into a final assessment. The depth and focus of the information seeking and processing vary depending on several factors.

Conclusion

The assessment of work capacity is a complex task where physicians rely on their non-medical skills to a higher degree than in ordinary clinical work. These skills are highly relevant but need to be complemented with access to appropriate resources such as understanding of the associations between health, work and social security, enough time in daily work for the assessment and ways to better understand the patient’s work place. Also, the notion of an “objective” evaluation is questioned, calling for a greater appreciation of the complexity of the assessment and the role of professional judgement.

Independent medical evaluation of general practitioners' follow-up of sick-listed patients: a cross-sectional study in Norway

OBJECTIVES

The study was designed to examine the sufficiency of general practitioners' (GPs) follow-up of patients on sick leave, assessed by independent medical evaluators.

DESIGN

Cross-sectional study SETTING: Primary health care in the Western part of Norway. The study reuses data from a randomised controlled trial-the Norwegian independent medical evaluation trial (NIME trial).

PARTICIPANTS

The intervention group in the NIME trial: Sick-listed workers having undergone an independent medical evaluation by an experienced GP at 6 months of unremitting sick leave (n=937; 57% women). In the current study, the participants were distributed into six exposure groups defined by gender and main sick leave diagnoses (women/musculoskeletal, men/musculoskeletal, women/mental, men/mental, women/all other diagnoses and men/all other diagnoses).

OUTCOME MEASURE

The independent medical evaluators assessment (yes/no) of the sufficiency of the regular GPs follow-up of their sick-listed patients.

RESULTS

Estimates from generalised linear models demonstrate a robust association between men with mental sick leave diagnoses and insufficient follow-up by their regular GP first 6 months of sick leave (adjusted relative risk (RR)=1.8, 95% CI=1.15-1.68). Compared with the reference group, women with musculoskeletal sick leave diagnoses, this was the only significant finding. Men with musculoskeletal diagnoses (adjusted RR=1.4, 95% CI=0.92-2.09); men with other diagnoses (adjusted RR=1.0, 95% CI=0.58-1.73); women with mental diagnoses (adjusted RR=1.2, 95% CI=0.75-1.77) and women with other diagnoses (adjusted RR=1.3, 95% CI=0.58-1.73).

CONCLUSIONS

Assessment by an independent medical evaluator showed that men with mental sick leave diagnoses may be at risk of insufficient follow-up by their GP. Efforts should be made to clarify unmet needs to initiate relevant actions in healthcare and work life. Avoiding marginalisation in work life is of the utmost importance.

TRIAL REGISTRATION NUMBER

NCT02524392; Post-results.

Sickness Certification Behavior amongst Primary Care Physicians: A Descriptive Analysis of Indirect Measures Using the Theory of Planned Behavior

Background

The provision of sick leave to patients in general practice often entails a complex decision-making process. Commonly, general practitioners believe that the act of providing sick leave can become confrontational. We assessed the intention, attitude, subjective norm, and perceived behavioral control of general practitioners in relation to sick leave provision at public health clinics in Malaysia.

Methods

A cross-sectional study design was implemented using data from 86 primary health care clinics in two states in Malaysia from February 2014 to March 2015. A questionnaire that comprised indirect measures were developed on the basis of the Theory of Planned Behavior. The questionnaire assessed several dimensions related to sickness certification provision viz., intention, attitude, subjective norm, and perceived behavioral control.

Results

The mean scores in this study revealed that physicians acknowledged that patient factors such as clinical symptoms (6.59±0.04), debilitating signs and symptoms of diseases (6.45±0.06), importance of illness recovery (6.07±0.07), and approval of employers (5.35±0.09) played an important role in their decision to provide sick leave.

Conclusion

The act of providing sickness certification to patients is a complex decision-making process. The findings of this study can be used to devise a targeted intervention to reduce the conflict that physicians face in issuing sick leaves.

Pain drawings, interpreter support and clinical findings among immigrant patients on sick leave in Swedish primary health care

Aim:

To evaluate the spread of pain and its correlates among immigrant patients on sick leave.

Background:

Backache, outspread pain and sick-leave questions are problematic to handle primary health care, especially in multicultural settings.

Methods:

Two hundred and thirty-five patients 20–45 years on paid sick leave (59% women, 93% foreign-born, mostly non-Europeans). Many had little formal education. One-third had professional interpreter support. The patients pointed out on their bodies where they felt pain. This information was transferred on a pain drawing [pain drawing fields (PDFs) 0–18] by a doctor. Major depression and psychosocial stressors were assessed using Diagnostic and Statistical Manual of Mental Disorders. Nociceptive locations for pain were established (pain-sites 0–18). Dependent variable was the number of PDFs. Independent variables were social data, sick leave, interpreter, depression, stress levels and number of pain sites. Calculations were done using descriptive methods and multi-variable linear regression in full models, by gender.

Findings:

Many patients had depression (51% women versus 32% men). A majority were exposed to psychosocial stressors. Women had more PDFs, in median 5 [inter-quartile ranges (IQR) 4–8] versus men 3 (IQR 2–5), and also more pain sites, in median 3 (IQR 2–5) versus men in median 2 (IQR 1–3). For men, the regression calculations revealed that numbers of PDFs associated only with increasing numbers of pain sites (B 0.871 P < 0.001). For women, this association was weaker (B 0.364, P < 0.001), with significant values also for age (B 0.103) and sick leave > one year (B 0.767, P = 0.010), and a negative predicting value for interpreter support (B −1.198, P < 0.043). To conclude, PDFs associated often with somatic findings but varied much among the women. This implies potential problems regarding cause, function and sick leave questions. However, support by professional interpreters may facilitate a shared understanding with immigrant women having long-standing pain.

Self-certification versus physician certification of sick leave for reducing sickness absence and associated costs

BACKGROUND

From the societal and employers' perspectives, sickness absence has a large economic impact. Internationally, there is variation in sickness certification practices. However, in most countries a physician's certificate of illness or reduced work ability is needed at some point of sickness absence. In many countries, there is a time period of varying length called the 'self-certification period' at the beginning of sickness absence. During that time a worker is not obliged to provide his or her employer a medical certificate and it is usually enough that the employee notifies his or her supervisor when taken ill. Self-certification can be introduced at organisational, regional, or national level.

OBJECTIVES

To evaluate the effects of introducing, abolishing, or changing the period of self-certification of sickness absence on: the total or average duration (number of sickness absence days) of short-term sickness absence periods; the frequency of short-term sickness absence periods; the associated costs (of sickness absence and (occupational) health care); and social climate, supervisor involvement, and workload or presenteeism (see Figure 1).

SEARCH METHODS

We conducted a systematic literature search to identify all potentially eligible published and unpublished studies. We adapted the search strategy developed for MEDLINE for use in the other electronic databases. We also searched for unpublished trials on ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We used Google Scholar for exploratory searches.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), controlled before-after (CBA) studies, and interrupted time-series (ITS) studies for inclusion. We included studies carried out with individual employees or insured workers. We also included studies in which participants were addressed at the aggregate level of organisations, companies, municipalities, healthcare settings, or general populations. We included studies evaluating the effects of introducing, abolishing, or changing the period of self-certification of sickness absence.

DATA COLLECTION AND ANALYSIS

We conducted a systematic literature search up to 14 June 2018. We calculated missing data from other data reported by the authors. We intended to perform a random-effects meta-analysis, but the studies were too different to enable meta-analysis.

MAIN RESULTS

We screened 6091 records for inclusion. Five studies fulfilled our inclusion criteria: one is an RCT and four are CBA studies. One study from Sweden changed the period of self-certification in 1985 in two districts for all insured inhabitants. Three studies from Norway conducted between 2001 and 2014 changed the period of self-certification in municipalities for all or part of the workers. One study from 1969 introduced self-certification for all manual workers of an oil refinery in the UK.Longer compared to shorter self-certificationfor reducing sickness absence in workersOutcome: average duration of sickness absence periodsExtending the period of self-certification from one week to two weeks produced a higher mean duration of sickness absence periods: mean difference in change values between the intervention and control group (MD_change) was 0.67 days/period up to 29 days (95% confidence interval (95% CI) 0.55 to 0.79; 1 RCT; low-certainty evidence).The introduction of self-certification for a maximum of three days produced a lower mean duration of sickness absence up to three days (MD_change -0.32 days/period, 95% CI -0.39 to -0.25; 1 CBA study; very low-certainty evidence). The authors of a different study reported that prolonging self-certification from ≤ 3 days to ≤ 365 days did not lead to a change, but they did not provide numerical data (very low-certainty evidence).

OUTCOME

number of sickness absence periods per workerExtending the period of self-certification from one week to two weeks resulted in no difference in the number of sickness absence periods in one RCT, but the authors did not report numerical data (low-certainty evidence).The introduction of self-certification for a maximum of three days produced a higher mean number of sickness absence periods lasting up to three days (MD_change 0.48 periods, 95% CI 0.33 to 0.63) in one CBA study (very low-certainty evidence).Extending the period of self-certification from three days to up to a year decreased the number of periods in one CBA study, but the authors did not report data (very low-certainty evidence).

OUTCOME

average lost work time per 100 person-yearsExtending the period of self-certification from one week to two weeks resulted in an inferred increase in lost work time in one RCT (very low-certainty evidence).Extending the period of self-certification (introduction of self-certification for a maximum of three days (from zero to three days) and from three days to five days, respectively) resulted in more work time lost due to sickness absence periods lasting up to three days in two CBA studies that could not be pooled (MD_change 0.54 days/person-year, 95% CI 0.47 to 0.61; and MD_change 1.38 days/person-year, 95% CI 1.16 to 1.60; very low-certainty evidence).Extending the period of self-certification from three days up to 50 days led to 0.65 days less lost work time in one CBA study, based on absence periods lasting between four and 16 days. Extending the period of self-certification from three days up to 365 days resulted in less work time lost due to sickness absence periods longer than 16 days (MD_change -2.84 days, 95% CI -3.35 to -2.33; 1 CBA study; very low-certainty evidence).

OUTCOME

costs of sickness absence and physician certificationOne RCT reported that the higher costs of sickness absence benefits incurred by extending the period of self-certification far outweighed the possible reduction in costs of fewer physician appointments by almost six to one (low-certainty evidence).In summary, we found very low-certainty evidence that introducing self-certification of sickness absence or prolonging the self-certification period has inconsistent effects on the mean number of sickness absence days, the number of sickness absence periods, and on lost work time due to sickness absence periods.

AUTHORS' CONCLUSIONS

There is low- to very low-certainty evidence of inconsistent effects of changing the period of self-certification on the duration or frequency of short-term sickness absence periods or the amount of work time lost due to sickness absence. Because the evidence is of low or very low certainty, more and better studies are needed.

Affecting patients with work-related problems by educational training of their GPs: a cost-effectiveness study

Background

Assessing the cost effectiveness of training aimed at increasing general practitioners’ (GP) work awareness and patients’ work-related self-efficacy and quality of life.

Methods

A cluster randomized controlled trial in twenty-six GP practices in the southeast of the Netherlands with 32 participating GPs. GPs working in an intervention group practice received training and GPs working in a control group practice delivered usual care. The training intervention consisted of lectures and workshops aimed at increasing GPs’ work awareness and more proactive counseling for patients with work-related problems (WRP). Subjects were working age patients with paid work for at least 12 h per week, who visited one of the participating GPs during the study period. As outcome measures we used the Return to Work Self Efficacy scale to assess patients’ work-related self-efficacy and the Euroquol to assess quality of life. We also measured health care costs and productivity costs. With a 4-item questionnaire we asked patients to assess their GPs’ work awareness. Data were collected at baseline, after 6 and 12 months.

Results

Data of 280 patients could be analyzed. The patient related outcomes did not improve after GP training. The change in GP work awareness and the overall mean cost difference (of €770) in favor of the intervention group were not significant.

Conclusions

The training intervention presented in this paper was not cost-effective. Training which is further personalized and targeted at high risk groups with respect to WRP, is more likely to be cost effective.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0924-9) contains supplementary material, which is available to authorized users.

Unsanctioned techniques for having sickness certificates accepted: a qualitative exploration and description of the strategies used by Swedish general practitioners

OBJECTIVES

To explore informal and unsanctioned techniques general practitioners (GPs) employ as a means to increase the likelihood of sickness certificate approval, following the Swedish Social Insurance Agency's (SSIA's) consolidation of the gatekeeping role in sickness benefit evaluation.

DESIGN

Qualitative semi-structured interviews with 20 GPs working in Swedish primary care. A thematic analysis of the transcribed material was carried out to map different techniques employed by the practitioners.

RESULTS

Eight techniques were identified, particularly with respect to the way in which the sickness certificate is written to ensure approval by the SSIA. The identified techniques were most commonly adopted when the patient's case was perceived to be at high risk for rejection by the SSIA (such as psychiatric illnesses, chronic pain etc.).

CONCLUSIONS

The findings imply that the informal and unsanctioned techniques are complex and ambiguous. They are used intentionally and covertly. The study also suggests that, while the consolidation of SSIA's gatekeeping role may have resolved some sickness absence issues, a consequence may be that GPs develop unsanctioned techniques to ensure compliance.

Acting by persuasion- values and rhetoric in medical certificates of work incapacity: A qualitative document analysis

When the patient applies for disability benefit in Norway, the general practitioner (GP) is required by the National Insurance Administration (NAV) to confirm that the patient is unfit for work due to disease. Considering the important social role of medical certificates, they have been given surprisingly little attention by the medical critique. They may make essential differences to peoples' lives, legitimise large social costs and, in addition, the GPs report that issuing certificates can be problematic. This article explores values, attitudes and persuasive language in a selection of medical certificates written by GPs. We direct attention to such texts as significant social actors using a mixed rhetoric including certain values and attitudes. When arguing for granting the patient disability benefit, some GPs emphasised the 'worthiness' of the patient by pointing to positive attitudes approved by the national insurance: a will to work and participate, to cooperate and be motivated. Others pointed out the patient's positive character in terms of universally accepted values, called for the reader's (the NAV official) sympathy , understanding and helpfulness or appealed to his/her willingness to be realistic and pragmatic and grant disability benefit (DB). The dialogic style varied: some certifiers-although they argued for disability benefit-showed openness to possible opposing or alternative voices by displaying their own uncertainty. Others addressed the reader to share responsibility, demanding or urging for DB. This shifting rhetoric, we believe, mirrors that the GPs see themselves as the patient's advocate, and that they may find themselves conflicted. We propose further studies within qualitative research to investigate the effect of this rhetoric on the reader, the decision-makers. In addition, to improve the quality and accuracy of these important documents, we suggest that medical schools introduce students to the making of text as a specific skill of medical practice.

Sick leave assessments of workers with subjective health complaints: a cross-sectional study on differences among physicians working in occupational health care

Aims: To obtain more insight into differences in sick leave assessments of workers with subjective health complaints, we studied sick leave assessments among Dutch occupational and insurance physicians, and explored possible determinants for these differences.Methods: A cross-sectional study was conducted among 50 occupational and 43 insurance physicians in the Netherlands. They all assessed sick leave (complete, partial or no) of nine video case vignettes of workers with subjective health complaints and gave their opinion on the complaints, sick leave and health status. Data were analyzed via a multinomial regression approach, using generalized estimating equations in SPSS.Results: Compared to occupational physicians, complete sick leave was less likely to be assessed by insurance physicians (odds ratio 0.74, 95% confidence interval 0.56-0.97). For occupational physicians, psychological diagnoses, private issues and reduced work ability had more influence on the outcome of the sick leave assessment than for insurance physicians.Conclusion: There are differences in sick leave assessments for workers with subjective health complaints between physicians working in the same occupational health system; insurance physicians are stricter in assessing complete sick leave than occupational physicians. These differences may be explained by differences in roles, tasks and perspectives of the physician in occupational health care.Implications for Rehabilitation  Sick leave assessments of workers with subjective health complaints.  • The current study showed that there are differences between occupational physicians and insurance physicians in sick leave assessments for workers with subjective health complaints.  • These differences may be based on different perspectives, roles and tasks of physicians.  • Physicians working in the rehabilitation and occupational health system should be more aware of the impact of these differences on their assessments and advices.  • Better communication and collaboration between physicians, and more insight into and clarification of the perspectives may result in more agreement between physicians' sick leave assessment and advice towards workers.

General practitioners' use of sickness certification guidelines in Sweden at introduction and four years later: a survey study

Objective

National sickness certification guidelines were introduced in Sweden in 2007, comprising both overarching and diagnoses-specific recommendations. This study aimed to investigate how general practitioners (GP) used and perceived the usefulness of these guidelines in the sickness certification process close after introduction and 4 years later.

Design

Two nationwide cross-sectional surveys in 2008 and 2012.

Setting

Swedish healthcare.

Participants

Physicians working in primary healthcare and having sickness certification consultations at least a few times per year (n = 4214 in 2008, and n = 4067 in 2012).

Main Outcome Measures

Frequency of use and perceived usefulness of the sickness certification guidelines.

Results

Most GPs used the guidelines at least a few times per year (in 2008 74.6%; in 2012 85.2%). In 2008, 44.1% reported a need to develop competence in using the guidelines, compared with 23.3% in 2012. Of those using the guidelines, 36.7% in 2008 and 44.6% in 2012 reported it problematic to write sickness certificates in accordance with the guidelines. Most GPs (89.2% in 2008 and 88.8% in 2012) valued the guidelines beneficial to ensure quality in sickness certification consultations. A larger proportion in 2012 compared with 2008 reported that the guidelines facilitated contacts with patients (61.2%, respectively, 55.6%), as well as with other stakeholders.

Conclusions

The guidelines were perceived as useful and beneficial to ensure high quality in sickness certification consultations, and facilitated contacts with patients as well as other stakeholders. In 2012, still one-fourth reported a need to develop more competence in using the sickness certification guidelines.

Insurers' Influences on Attending Physicians of Workers Sick-listed for Common Mental Disorders: What Are the Impacts on Physicians' Practices?

Purpose In many jurisdictions, general practitioners (GPs) play an important role in the sick-leave and return-to-work (RTW) process of individuals with common mental disorders (CMD). Since it is insurers that decide on workers' eligibility for disability benefits, they can influence physicians' ability to act. The nature of these influences remains little documented to date. The aim of this study was therefore to describe these influences and their impacts from the GPs' perspective. Methods Semi-structured interviews were conducted with GPs having a diversified clientele (n = 13). The interviews were audio-recorded, transcribed verbatim and analyzed according to thematic analysis principles. Results The results indicated that the GPs recognized insurers as influencing their practices with patients on sick leave for CMDs. The documented influences were generally seen as constraints, but sometimes as enablers. The impacts of these influences on the GPs' practices depended on the organizational characteristics of their work context (such as limited consultation time) and other characteristics of their practice setting (such as lack of timely access to consultations with specialists). Conclusion The results brought three major issues to light: the quality of the information sent to insurers by GPs, the respect shown (or not) for workers' care preferences, and the relevance of the specialized services offered to support workers' RTW. These issues in turn reveal potential risks for workers, risks that need to be identified and recognized by all parties concerned if we are to come up with possible solutions.

Independent medical evaluation for sick-listed patients: a focus group study of GPs´ expectations and experiences

BACKGROUND

Norwegian general practitioners (GPs) are important stakeholders because they manage 80% of people on long-term sick-leave. Independent medical evaluation (IME) for long-term sick-listed patients is being evaluated in a large randomized controlled trial in one county in Norway in an effort to lower the national sick-leave rate (the NIME trial: Effect Evaluation of IME in Norway). The aim of the current study was to explore GPs' expectations of and experiences with IMEs.

METHODS

We conducted three focus group interviews with a convenience sample of 14 GPs who had had 2-9 (mean 5) of their long-term sick-listed patients summoned to an IME. We asked them to recollect and describe their concrete expectations of and experiences with patients assigned to an IME. Systematic text condensation, a method for thematic cross-case analysis, was applied for analysis.

RESULTS

To care for and to reassure their assigned sick-listed patients, the participants had spent time and applied different strategies before their patients had attended an IME. The participants welcomed a second opinion from an experienced GP colleague as a way of obtaining constructive advice for further sick-leave measures and/or medical advice. However, they mainly described the IME reports in negative terms, as these were either too categorical or provided unusable advice for further follow-up of their sick-listed patients. The participants did not agree with the proposed routine use of IMEs but instead suggested that GPs should be able to select particularly challenging sick-listed patients for an IME, which should be performed by a peer.

CONCLUSION

Our participants showed positive attitudes towards second opinions but found the regular IMEs to be unsuitable. The participants did however welcome IMEs if they themselves could select particularly challenging patients for a mandatory second opinion by a peer but emphasized that IME-doctors should not be able to overrule a GP's sick-leave recommendation. These findings, together with other evaluations, will serve as a basis for the Norwegian government's decision on whether or not to implement IMEs for long-term sick-listed patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02524392 . Registered 23 June, 2015.

The capacity to work puzzle: a qualitative study of physicians' assessments for patients with common mental disorders

BACKGROUND

Entitlement to sickness benefits is a legal process requiring health-related reduced work capacity confirmed by a physician via a sickness certificate. However, there is a knowledge gap concerning physicians' clinical practice of work capacity assessments for patients with common mental disorders (CMD). Physicians claim more knowledge and skills in how to actually do the assessments. The aim of this study was to explore physicians' tacit knowledge of performing assessments of capacity to work and the need for sickness absence in patients with depression and anxiety disorders.

METHODS

We performed a qualitative study with open-ended interviews and a short video vignette of a physician and a patient with depression as stimuli. Participating physicians (n = 24) were specialized in general practice, occupational health or psychiatry and experienced in treating patients with depression and anxiety. Interviews were audio-recorded and transcribed verbatim. Inductive content analysis was used as the analytical tool.

RESULTS

Five categories were identified. Category 1 identified work capacity assessment as doing a jigsaw puzzle without any master model. The physicians both identified and created the pieces of the puzzle, mainly by facilitating strategies to make the patient a better supplier of essential information. The finished puzzle made up a highly individualized comprehensive picture required for adequate assessment. Categories 2-4 identified the particular essential pieces of information the participants used, relating to the patient's disorder, capacity in the work place and contextual everyday life. For the sickness absence assessment, apart from decreased work capacity, the physicians also took particulars of the work place into account; e.g. could the work place handle an employee with reduced capacity.

CONCLUSIONS

Physicians' tacit knowledge of assessing work capacity and the need for sickness absence for patients with CMD was identified as doing a jigsaw puzzle. The physicians became identifiers and creators of the pieces of the puzzle using a broad palette of essential information. Our findings contribute to the knowledge gap on clinical assessment and can be used as an educational tool. Because they are based on the professions' tacit knowledge, acceptance of the model can be expected to be high.

Can chiropractors contribute to work disability prevention through sickness absence management for musculoskeletal disorders? - a comparative qualitative case study in the Scandinavian context

Background

Despite extensive publication of clinical guidelines on how to manage musculoskeletal pain and back pain in particular, these efforts have not significantly translated into decreases in work disability due to musculoskeletal pain. Previous studies have indicated a potential for better outcomes by formalized, early referral to allied healthcare providers familiar with occupational health issues. Instances where allied healthcare providers of comparable professional characteristics, but with differing practice parameters, can highlight important social and organisational strategies useful for informing policy and practice. Currently, Norwegian chiropractors have legislated sickness certification rights, whereas their Danish and Swedish counterparts do not. Against the backdrop of legislative variation, we described, compared and contrasted the views and experiences of Scandinavian chiropractors engaging in work disability prevention and sickness absence management.

Methods

This study was embedded in a two-phased, sequential exploratory mixed-methods design. In a comparative qualitative case study design, we explored the experience of chiropractors regarding sickness absence management drawn from face-to-face, semi-structured interviews. We subsequently coded and thematically restructured their experiences and perceptions.

Results

Twelve interviews were conducted. Thematically, chiropractors' capacity to support patients in sickness absence management revolved around four key issues: issues of legislation and politics; the rationale for being a sickness absence management partner; whether an integrated sickness absence management pathway existed/could be created; and finally, the barriers to service provision for sickness absence management.

Conclusion

Allied health providers, in this instance chiropractors, with patient management expertise can fulfil a key role in sickness absence management and by extension work disability prevention when these practices are legislatively supported. In cases where these practices occur informally, however, practitioners face systemic-related issues and professional self-image challenges that tend to hamper them in fulfilling a more integrated role as providers of work disability prevention practices.

Physicians’ experiences with sickness absence certification in Finland

Aims: The aim of this study was to explore Finnish physicians’ perceptions of sickness absence (SA) certification. Methods: A questionnaire was sent to 50% of the physicians in Finland who provide care to working-age patients in a clinical practice setting. Of the 8867 physicians, 3089 responded. Physicians handling SA certification patients at least a few times per month were included ( n = 2472). Results: At least a few times per month, 61% of all physicians perceived SA issues as problematic, 60% had experienced a lack of time in dealing with SA matters, 36% had disagreed with a patient on SA certification, and 36% had met a patient who wanted a SA certificate for reasons other than a disease or injury. Physicians were least worried about patients filing complaints (4%), exhibiting threatening behaviour (2%), or switching physicians for SA certification reasons (1%). A total of 60% of physicians had prescribed SA for a longer period than necessary because of long waiting times for further care/measures. Non-specialized physicians, general practitioners, and psychiatrists experienced problems more frequently than surgeons and occupational health physicians. Over 50% of the respondents had a fairly large or very large need to deepen their knowledge of social insurance matters. The need for national guidelines for all or some diseases was reported by 80% of the respondents. Conclusions: Many physicians perceive SA tasks as problematic and are unable to dedicate enough time to them. Shortcomings in physicians’ sickness certification know-how, as well as obstacles in the healthcare and rehabilitation system, prolong the SA process. Attitudes towards the adoption of national guidelines on the duration of SA were positive.

Assessing predictors of intention to prescribe sick leave among primary care physicians using the theory of planned behaviour

Background

Providing sickness certification is a decision that primary care physicians make on a daily basis. The majority of sickness certification studies in the literature involve a general assessment of physician or patient behaviour without the use of a robust psychological framework to guide research accuracy. To address this deficiency, this study utilized the Theory of Planned Behaviour (TPB) to specifically gauge the intention and other salient predictors related to sickness certification prescribing behaviour amongst primary care physicians.

Methods

A cross-sectional study was conducted among N = 271 primary care physicians from 86 primary care practices throughout two states in Malaysia. Questionnaires used were specifically developed based on the TPB, consisting of both direct and indirect measures related to the provision of sickness leave. Questionnaire validity was established through factor analysis and the determination of internal consistency between theoretically related constructs. The temporal stability of the indirect measures was determined via the test-retest correlation analysis. Structural equation modelling was conducted to determine the strength of predictors related to intentions.

Results

The mean scores for intention to provide patients with sickness was low. The Cronbach α value for the direct measures was good: overall physician intent to provide sick leave (0.77), physician attitude towards prescribing sick leave for patients (0.77) and physician attitude in trusting the intention of patients seeking sick leave (0.83). The temporal stability of the indirect measures of the questionnaire was satisfactory with significant correlation between constructs separated by an interval of two weeks (p < 0.05). Attitudes and subjective norms were identified as important predictors in physician intention to provide sick leave to patients.

Conclusion

An integrated behavioural model utilizing the TPB could help fully explain the complex act of providing sickness leave to patients. Findings from this study could assist relevant agencies to facilitate the creation of policies that may help regulate the provision of sickness leave and alleviate the work burden of sickness leave tasks faced by physicians in Malaysia.

Electronic supplementary material

The online version of this article (10.1186/s12875-017-0690-5) contains supplementary material, which is available to authorized users.

Collaborative case management to aid return to work after long-term sickness absence: a pilot randomised controlled trial

Background

Despite high levels of employment among working-age adults in the UK, there is still a significant minority who are off work with ill health at any one time (so-called ‘sickness absence’). Long-term sickness absence results in significant costs to the individual, to the employer and to wider society.

Objective

The overall objective of the intervention was to improve employee well-being with a view to aiding return to work. To meet this aim, a collaborative case management intervention was adapted to the needs of UK employees who were entering or experiencing long-term sickness absence.

Design

A pilot randomised controlled trial, using permuted block randomisation. Recruitment of patients with long-term conditions in settings such as primary care was achieved by screening of routine records, followed by mass mailing of invitations to participants. However, the proportion of patients responding to such invitations can be low, raising concerns about external validity. Recruitment in the Case Management to Enhance Occupational Support (CAMEOS) study used this method to test whether or not it would transfer to a population with long-term sickness absence in the context of occupational health (OH).

Participants

Employed people on long-term sickness absence (between 4 weeks and 12 months). The pilot was run with two different collaborators: a large organisation that provided OH services for a number of clients and a non-profit community-based organisation.

Intervention

Collaborative case management was delivered by specially trained case managers from the host organisations. Sessions were delivered by telephone and supported use of a self-help handbook. The comparator was usual care as provided by participants’ general practitioner (GP) or OH provider. This varied for participants according to the services available to them. Neither participants nor the research team were blind to randomisation.

Main outcome measures

Recruitment rates, intervention delivery and acceptability to participants were the main outcomes. Well-being, as measured by the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), and return-to-work rates were also recorded.

Results

In total, over 1000 potentially eligible participants were identified across the sites and invited to participate. However, responses were received from just 61 of those invited (5.5%), of whom 16 (1.5%) were randomised to the trial (seven to treatment, nine to control). Detailed information on recruitment methods, intervention delivery, engagement and acceptability is presented. No harms were reported in either group.

Conclusions

This pilot study faced a number of barriers, particularly in terms of recruitment of employers to host the research. Our ability to respond to these challenges faced several barriers related to the OH context and the study set up. The intervention seemed feasible and acceptable when delivered, although caution is required because of the small number of randomised participants. However, employees’ lack of engagement in the research might imply that they did not see the intervention as valuable.

Future work

Developing effective and acceptable ways of reducing sickness absence remains a high priority. We discuss possible ways of overcoming these challenges in the future, including incentives for employers, alternative study designs and further modifications to recruitment methods.

Trial registration

Current Controlled Trials ISRCTN33560198.

Funding

This project was funded by the NIHR Public Health Research programme and will be published in full inPublic Health Research; Vol. 6, No. 2. See the NIHR Journals Library website for further project information.

Independent medical evaluation for sick-listed workers in Norway: A focus group study of the experience of IME doctors

BACKGROUND

Norwegian politicians have proposed the use of an independent medical evaluation (IME) as a possible solution for reducing long-term sick leave. The use of an IME implies that a new doctor interferes in the relationship between sick-listed workers and their general practitioner (GP). The aim of the current study was to explore experiences of IME doctors from an ongoing randomized controlled trial (the NIME trial evaluating the effect of IME in Norway).

METHODS

Two focus group interviews were conducted with eight of the nine IME doctors employed in the NIME trial. The discussions were audio-taped and transcribed. Systematic text condensation was used for analysis.

RESULTS

The participants reported that the IME provides important second opinions, which they felt empowered the sick-listed workers and provided new insights into their condition. Beneficial IME working conditions and enhanced insight into different sick leave measures were crucial to this perceived usefulness. Some of the participants expressed disappointment with GPs acting as passive conductors and struggled to provide feedback politely. Some adjustments were proposed as necessary for the IME to be implemented nationwide.

CONCLUSIONS

The participants seemed to have gained a different stakeholder identity by sometimes seeing GPs, their peers, as obstacles to return to work and welcomed the use of IME on a regular basis.

Case-specific colleague guidance for general practitioners' management of sickness absence

Background

General practitioners (GPs) report sickness absence certification as challenging. They express need for support with functional assessment beyond guidelines and reforms. Case-specific collegial one-to-one guidance for other clinical topics has proved popular with GPs and may be an acceptable and effective way to improve GPs skills and competence in sickness absence certification.

Aims

To present a new model of case-specific colleague guidance focusing on the management of long-term sickness absence and to describe its feasibility in terms of application and reception among GPs, and also GPs' self-reports of effects on their practice.

Methods

Randomly selected GPs received case-specific collegial guidance over a 12-month period, in two Norwegian trials, delivered by former GPs employed by the social security administration. We measured reception and perceived effects by GPs' self-report and registered participation and withdrawal rates.

Results

The participation rate (n = 165) was 94%, and no GPs withdrew during training. Among the 116 GPs responding to the survey (70%), 112 (97%; 95% CI 92-99) stated they would recommend it to their colleagues. Considerable benefit from the guidance was reported by 68 (59%; 95% CI 50-68). The GPs self-reported other effects on their sickness absence certification, specifically an increased use of part-time sickness absence (Fit-Note equivalent).

Conclusions

This model of case-specific colleague guidance to aid GPs' management of long-term sickness absence is feasible and was popular. This type of guidance was perceived by GPs to be somewhat beneficial and to alter their sickness absence certification behaviour, though the true impact requires further testing in controlled trials.

Neurologists dealing with sickness certification: Experiences of problems and need of competence

RATIONALE AND AIMS

Most studies on physicians' sickness certification practices include general practitioners (GP) while there hardly is any knowledge on this regarding neurologists although neurological diseases often involve work incapacity and need of sick leave.

AIM

The aim was to describe experiences among neurologists in Sweden concerning their work with sickness certification of patients.

METHOD

A cross-sectional study of 265 neurologists' responses in a nationwide survey regarding their work with sickness certification of patients was conducted.

RESULTS

The majority (81.5%) had sickness certification consultations at least once a week and a third experienced problems every week in handling sickness certification. Among the 251 who at least sometimes had sickness certification consultations, the following two aspects were experienced as very or fairly problematic: "assess the degree to which the reduced functional capacity limits a patient's capacity to perform his/her work assignments" (67.3%) and "make a long-term prognosis about the future work capacity of patients on sick leave" (60.5%). At least once a week, 78.7% experienced lack of time regarding managing patient-related aspects of the sickness certification task. Moreover, 21.8% considered sickness certification to be a work environmental problem, at least once a week. In all, 84% stated that they had a large or fairly large need for more competence concerning sickness certification tasks.

CONCLUSIONS

Sickness certification is a common task among neurologists, involving several problematic aspects related to, e.g., lack of competence in assessing function and work capacity and of time. There is a need for improvement.

'Working is out of the question': a qualitative text analysis of medical certificates of disability

Background

Medical certificates influence the distribution of economic benefits in welfare states; however, the qualitative aspects of these texts remain largely unexplored. The present study is the first systematic investigation done of these texts. Our aim was to investigate how GPs select and mediate information about their patients’ health and how they support their conclusions about illness, functioning and fitness for work in medical certificates.

Methods

We performed a textual analysis of thirty-three medical certificates produced by general practitioners (GP) in Norway at the request of the Norwegian Labour and Welfare Administration (NAV).The certificates were subjected to critical reading using the combined analytic methods of narratology and linguistics.

Results

Some of the medical information was unclear, ambiguous, and possibly misleading. Evaluations of functioning related to illness were scarce or absent, regardless of diagnosis, and, hence, the basis of working incapacity was unclear. Voices in the text frequently conflated, obscuring the source of speaker. In some documents, the expert’s subtle use of language implied doubts about the claimant’s credibility, but explicit advocacy also occurred. GPs show little insight into their patients’ working lives, but rather than express uncertainty and incompetence, they may resort to making too absolute and too general statements about patients’ working capacity, and fail to report thorough assessments.

Conclusions

A number of the texts in our material may not function as sufficient or reliable sources for making decisions regarding social benefits. Certificates as these may be deficient for several reasons, and textual incompetence may be one of them. Physicians in Norway receive no systematic training in professional writing. High-quality medical certificates, we believe, might be economical in the long term: it might increase the efficiency with which NAV processes cases and save costs by eliminating the need for unnecessary and expensive specialist reports. Moreover, correct and coherent medical certificates can strengthen legal protection for claimants. Eventually, reducing advocacy in these documents may contribute to a fairer evaluation of whether claimants are eligible for disability benefits or not. Therefore, we believe that professional writing skills should be validated as an important part of medical practice and should be integrated in medical schools and in further education as a discipline in its own right, preferably involving humanities professors.

Work disabilities and unmet needs for health care and rehabilitation among jobseekers: a community-level investigation using multidimensional work ability assessments

OBJECTIVE

Comprehensive understanding of the prevalence and quality of work disabilities and unmet needs for health care and rehabilitation to support return to work (RTW) among jobseekers.

DESIGN

Community-level, cross-sectional analysis with multidimensional clinical work ability assessments.

SETTING

Paltamo, Finland.

PARTICIPANTS

Unemployed citizens either participating in the Full-Employment Project or long-term unemployed (n = 230, 81%).

MAIN OUTCOME MEASURES

Based on data from theme interviews, patient records, supervisors' observations of work performance and clinical examinations, a physician concluded the individual's work ability, categorised into four groups: good work ability, good work ability expected after RTW support, able to transitional work only or unable to work. These groups were cross tabulated with primary diagnoses, types of plans to support RTW, as well as categories of social functioning and motivation, for which sensitivity and specificity scores in detecting work disability were calculated.

RESULTS

Only about half of the jobseekers had good work ability, 27% were found unable to work in the open labour market and 15% even eligible for a disability pension. For 20%, care or rehabilitation was seen necessary to enable RTW. Poor supervisor- and self-rated performance at work or poor social functioning appeared as sensitive measures in detecting work disability.

CONCLUSIONS

Work disabilities and unmet needs for health care and rehabilitation are highly prevalent among jobseekers, as depicted using a multidimensional work ability assessment procedure inspired by the International Classification of Functioning (ICF). Further development of work ability assessment practices is clearly needed. KEY POINTS Although the association of unemployment with poor health is well known, evidence on the work ability of the unemployed remains scarce. Work disabilities are common among the unemployed. Multidimensional work ability assessment among the unemployed reveals unmet needs for care and rehabilitation to support return to work. Context sensitivity may add to the accuracy of the doctor's conclusions on work ability.

Obstetricians/Gynecologists' Problems in Sickness Certification Consultations: Two Nationwide Surveys

Objective. To explore experiences by physicians working in obstetrics, gynecology, or maternal healthcare (O/Gs) of problems in sickness certification consultations and differences between two years. Material and Methods. Answers by O/Gs to two Swedish nationwide surveys, in 2008 (n = 1037) and 2012 (n = 992), were analyzed for frequencies and severity of problems and organizational support in sickness certification consultations. Results. One-third of O/Gs found sickness certifications problematic every week. The most frequent problem was patients requesting sick notes for reasons other than work incapacity due to disease/injury (2008: 21%; 2012: 16%). The most problematic were assessing work capacity (2008 and 2012: 52%) and having different opinion from that of the patient about need for sick leave (2008: 51%; 2012: 46%). In 2012, 27% used the national sickness certification guidelines weekly, compared to 9% in 2008. A larger proportion in 2012 than 2008 reported that the guidelines facilitated contacts with patients and different stakeholders. Conclusions. Although O/Gs perceived sickness certification as problematic, there was less perceived severity of problems in 2012 compared to 2008, possibly because interventions regarding sickness certification have been introduced in Sweden recent years. Still, more organizational support, for example, time and supervision, are needed to enhance O/Gs' sickness certification practices.

Writing the patient down and out: the construal of the patient in medical certificates of disability

We analysed a set of medical certificates to investigate how GPs portray patients who seek disability benefits in Norway, focusing on patient centredness, agency and involvement. We performed a qualitative linguistic analysis of 33 medical certificates collected throughout Norway that were strategically selected based on the patients' sex, age and diagnosis. We found that patients were represented as passive carriers of symptoms, in whom agency was low, failed, conditional or non-existing, or as passive objects of the actions of impersonalised others. Conversely, symptoms were foregrounded as independent and powerful actors. The patient's experience of illness was sometimes reported, but the perspective of the GP tended to be doctor oriented, rather than patient centred. The policy of the social services, which emphasises patient involvement, patient centredness and work, rather than social benefits, was almost completely absent from these medical certificates. If medical certificates are to be a valid basis for decisions within the social services, we suggest that doctor paternalism in these documents must give way to considering the patient as an involved and co-responsible individual in the processes of disability assessment.

A synthesis of qualitative research exploring the barriers to staying in work with chronic musculoskeletal pain

PURPOSE

Qualitative research can help to advance our understanding, management and prevention of work disability. Our aim was to integrate qualitative research findings in order to increase our understanding of barriers to stay in work with chronic pain.

METHODS

We searched five electronic bibliographic databases until September 2012, supplemented by citation tracking and hand-searching. We used meta-ethnography to synthesis our findings. Central to meta-ethnography is identifying “concepts” and developing a conceptual model. Concepts were compared and organised into categories.

RESULTS

The following categories can have an impact on the decision to remain in work: struggling to affirm myself as a good worker; balancing life and work in the face of unpredictable symptoms; my work colleagues don't believe me; the system does not facilitate return to work; the battle for legitimacy.

CONCLUSIONS

Our innovation is to present an internationally relevant model based on a conceptual synthesis. This model highlights the adversarial work experience of people with chronic. The papers span 15 years of qualitative research. A significant finding is that these themes continue to pervade the current work environment for those in pain, and this has clear implications for education, social care and policy.

IMPLICATIONS FOR REHABILITATION

People with chronic pain face an adversarial struggle to maintain their credibility at work. Strategies to maintain personal credibility can have an adverse effect on working lives. Changes at a systems level are needed to facilitate continuance and return to work. Cultural changes in the way that we view people with pain would help to keep people in work.

How do general practitioners contribute to preventing long-term work disability of their patients suffering from depressive disorders? A qualitative study

BACKGROUND

Depression is a major cause of work absenteeism that general practitioners (GPs) face directly since they are responsible for sickness certification and for supervising the return to work (RTW). These activities give GPs a key role in preventing long-term work disability, yet their practices in this regard remain poorly documented. The objectives of this study were therefore to describe GPs' practices with people experiencing work disability due to depressive disorders and explore how GPs' work context may impact on their practices.

METHODS

We conducted semi-structured individual interviews with 13 GPs and six mental healthcare professionals in two sub-regions of Quebec. The sub-regions differed in terms of availability of specialized resources offering public mental health services. Data were anonymized and transcribed verbatim. Thematic analysis was performed to identify patterns in the GPs' practices and highlight impacting factors in their work context.

RESULTS

Our results identified a set of practices common to all the GPs and other practices that differentiated them. Two profiles were defined on the basis of the various practices documented. The first is characterized by the integration of the RTW goal into the treatment goal right from sickness certification and by interventions that include the workplace, albeit indirectly. The second is characterized by a lack of early RTW-oriented action and by interventions that include little workplace involvement. Regardless of the practice profile, actions intended to improve collaboration with key stakeholders remain the exception. However, two characteristics of the work context appear to have an impact: the availability of a dedicated mental health nurse and the regular provision of clinical information by psychotherapists. These conditions are rarely present but tend to make a significant difference for the GPs.

CONCLUSIONS

Our results highlight the significant role of GPs in the prevention of long-term work disability and their need for support through the organization of mental health services at the primary care level.

Stakeholder perspectives on the new sickness certificate in Victoria: results from a mixed-methods qualitative study

Objective The aim of this study was to present the views of four stakeholder groups, namely general practitioners (GP), employers (EMP), injured workers (IW) and compensation agents (CA), about the content and usability of the draft of the new Victorian sickness certificate. Methods A cross-sectional mixed-methods qualitative study was conducted in GP clinics and community settings in Melbourne, Australia. Interviews were conducted with GPs, EMPs and IWs and one focus group discussion was completed with CAs (n = 29). Data were collected between October and December 2013. Thematic analysis was performed. Results All stakeholders viewed the new draft certificate as an improvement on the old one. GPs saw the certificate as a form of communication, whereas EMPs and CAs saw it as a therapeutic device. GPs continued to certify based on incapacity and provided little information about what IWs could do on return to work. All groups said that assessments for mental health needed more clarity and specificity. GPs, EMPs and CAs also said that the new certificates must be electronically available and integrated into existing medical software to streamline uptake. Conclusions To ensure appropriate use of the new certificate, stakeholders must share a common understanding about its purpose and the certificate must be incorporated into existing medical software. Content on mental health assessment, an area of continued difficulty, needs additional refinement. The new certificate replaced the old certificate in March 2015; after it has been established in clinical practice, an impact evaluation should be completed to determine whether GPs are certifying capacity and earlier return to work. What is known about the topic? When it comes to sickness certification, GPs tend to focus on what injured patients cannot do, rather than what they can do. The new sickness certificate aims to change GP behaviour by focusing the certificate more on capacity (i.e. what the injured patient can do). What does this paper add? Four stakeholder groups agreed that the content and usability of the new certificate has improved. However, they agreed that the assessment of mental health capacity needs further specificity. Dissonances also remain between the stakeholders on the purpose of the certificate. What are the implications for practitioners? Appropriate use of the new certificate requires a common understanding about the purpose of the certificate, training on its appropriate use, incorporation into existing medical software and clarity on mental health assessment.

Irish GP attitudes towards sickness certification and the 'fit note'

BACKGROUND

Sickness certification poses significant challenges to most general practitioners (GPs). As an alternative form of certification, in 2010, the UK implemented the 'fit note', which focuses on returning to work after illness. It has been well received in the UK but little is known of non-UK GP attitudes towards the fit note.

AIMS

To evaluate the challenges Irish GPs experience with the current sickness certification system and their attitudes towards the fit note.

METHODS

A questionnaire assessing attitudes, practices and preferences regarding the fit note was developed, piloted and posted to a representative sample of Irish GPs selected by systematic sampling. Descriptive statistics, chi-square tests and binary logistic regression were used to analyse the results.

RESULTS

Of 305 GPs surveyed, 64% (196) completed the survey. Ninety per cent (177) of responders reported a lack of available rehabilitation services for patients on sick leave and 66% (124) reported adverse effects of sickness certification on therapeutic relationships with patients. Those who indicated a preference for introducing the fit note (53%; 104) were significantly more likely to endorse both an excessive focus on disability [odds ratio (OR) = 3.16] and lack of GP training (OR = 2.04) in the sickness certification process.

CONCLUSIONS

Difficulties associated with sickness certification are apparent at GP-patient, GP-employer and GP-health service levels. Addressing these will require intervention at each of these levels and may be facilitated by challenging the assumption that illness equates to disability.

General practitioners and sickness certification for injury in Australia

Background

Strong evidence supports an early return to work after injury as a way to improve recovery. In Australia, General Practitioners (GPs) see about 96 % of injured workers, making them the main gatekeepers to workers’ entitlements. Most people with compensable injuries in Australia are certified as “unfit to work” by their GP, with a minority of patients certified for modified work duties. The reasons for this apparent dissonance between evidence and practice remain unexplored. Little is known about the factors that influence GP sickness certification behaviour in Australia. The aim of this study is to describe the factors influencing Australian GPs certification practice through qualitative interviews with four key stakeholders.

Methods

From September to December 2012, 93 semi-structured interviews were undertaken in Melbourne, Australia. Participants included GPs, injured workers, employers and compensation agents. Data were thematically analysed.

Results

Five themes describing factors influencing GP certification were identified: 1. Divergent stakeholder views about the GP’s role in facilitating return to work; 2. Communication between the four stakeholder groups; 3. Conflict between the stakeholder groups; 4. Allegations of GPs and injured workers misusing the compensation system and 5. The layout and content of the sickness certificate itself.

Conclusion

By exploring GP certification practice from the perspectives of four key stakeholders, this study suggests that certification is an administrative and clinical task underpinned by a host of social and systemic factors. The findings highlight opportunities such as practice guideline development and improvements to the sickness certificate itself that may be targeted to improve GP sickness certification behaviour and return to work outcomes in an Australian context.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0307-9) contains supplementary material, which is available to authorized users.

Problems with sickness certification tasks: experiences from physicians in different clinical settings. A cross-sectional nationwide study in Sweden

BACKGROUND

Many physicians find sickness certification of patients problematic. The aims were to explore problems that physicians in different clinical settings experience with sickness certification tasks in general and with assessment of function, work capacity, and need for sick leave, as well as handling of sick-leave spells of different durations.

METHODS

Data from a questionnaire sent to 33,144 physicians aged <68 years, living and working in Sweden in 2012 were analysed. The response rate was 57.6%. The study group comprised the 12,933 responders who had sickness certification tasks. Frequencies and odds ratios with 95% confidence intervals were calculated for questions concerning how problematic the physicians experienced different assessments related to patients' function, work capacity, and need for sick leave, as well as handling sick-leave spells of different durations.

RESULTS

There were large differences between clinical settings regarding how often and to what extent sickness certification consultations were perceived as problematic. Physicians working in primary health care (PHC) had the highest proportions experiencing sickness certification consultations as problematic at least once a week (49.5%) and as very or fairly problematic (56.6%), followed by physicians working in psychiatry, pain management, or orthopaedics. More than half of the responders found it very or fairly problematic to assess patients' work capacity (57.8%), to make a long-term prognosis about patients' future work capacity (55.7%), and to handle long-term or very long-term sickness certifications (51.9% and 51.8%). The proportions were highest among physicians working in PHC, rheumatology, neurology, or psychiatry.

CONCLUSIONS

The rates of physicians finding sickness certification task problematic varied much with clinical setting, and were highest among physicians in PHC. More knowledge is needed about the work conditions and prerequisites for optimal handling of sickness certification in different clinical settings.

General practitioners' and occupational health physicians' views on their cooperation: a cross-sectional postal survey

PURPOSE

Prevention, rehabilitation and reintegration into the workplace are examples of overlapping work fields of general practitioners (GPs) and occupational health physicians (OPs). In Germany, however, cooperation between GPs and OPs is often lacking or suboptimal. In this article, we present GPs' and OPs' views on a variety of aspects of their cooperation and differences between them.

METHODS

Survey questionnaire was developed on the basis of literature research and results of focus group interviews. Cross-sectional postal survey among GPs (n = 1000) and OPs (n = 383) was performed in the federal state of Baden-Württemberg, Germany. Explorative descriptive and logistic regression analyses were carried out (controlling for potential confounders).

RESULTS

Response rates were 31 and 48 %, respectively. Mutual telephone calls were the most frequent contact medium (49 and 91 %, respectively). Both groups considered themselves to have clearly separate areas of responsibility (median = 4, rating scale from 1 "agree not at all" to 5 "agree definitely"). Necessity to cooperate and need to improve cooperation were both rated as 4 (by GPs) and 5 (by OPs), respectively (p < 0.001, Wilcoxon test). Several variables were found to be different by logistic regression analysis of answers from the two groups (e.g. in regard to importance of rehabilitation, primary prevention services, caring for chronically ill workers or changing of workplace conditions). Sensitive topics (e.g. concerning mutual rivalry, remuneration or adherence to medical confidentiality) were also found to be rated differently.

CONCLUSION

The data show potential interest of both physicians groups to develop cooperation. As the ratings often differed significantly, particularly in regard to statements presented, answers influenced by social desirability are generally unlikely.

Completion of fit notes by GPs: a mixed methods study

AIMS

The aim of this study was to investigate the completion of fit notes by UK general practitioners (GPs). A series of actual fit notes issued to employed patients were examined, and their GPs' reflections and experiences of fit note completion explored.

METHODS

A mixed-methods design was used. Data were collected from copies of 94 fit notes issued to employed patients by 11 GPs, and from 86 questionnaires completed by these GPs reflecting on the fit notes they had issued. Face-to-face interviews were then conducted with each GP.

RESULTS

Fit note completion is not meeting expectations for a number of reasons. These include the following: limited knowledge and awareness of the guidance in fit note completion; problems with the fit note format; lack of mandatory training in completing fit notes; lack of incentive to change practice; incomplete implementation of the electronic fit note; GPs' lack of confidence in, and doubts about the appropriateness of performing this role.

CONCLUSION

If UK GPs are to continue their contractual responsibility for completing fit notes, further consideration of their education and training needs is urgently required. Weaknesses in the design and format of the fit note and the availability of the electronic version also need to be addressed.

GPs' negotiation strategies regarding sick leave for subjective health complaints

OBJECTIVES

To explore general practitioners' (GPs') specific negotiation strategies regarding sick-leave issues with patients suffering from subjective health complaints.

DESIGN

Focus-group study.

SETTING

Nine focus-group interviews in three cities in different regions of Norway.

PARTICIPANTS

48 GPs (31 men, 17 women; age 32-65), participating in a course dealing with diagnostic practice and assessment of sickness certificates related to patients with subjective health complaints.

RESULTS

The GPs identified some specific strategies that they claimed to apply when dealing with the question of sick leave for patients with subjective health complaints. The first step would be to build an alliance with the patient by complying with the wish for sick leave, and at the same time searching for information to acquire the patient's perspective. This position would become the basis for the main goal: motivating the patient for a rapid return to work by pointing out the positive effects of staying at work, making legal and moral arguments, and warning against long-term sick leave. Additional solutions might also be applied, such as involving other stakeholders in this process to provide alternatives to sick leave.

CONCLUSIONS AND IMPLICATIONS

GPs seem to have a conscious approach to negotiations of sickness certification, as they report applying specific strategies to limit the duration of sick leave due to subjective health complaints. This give-and-take way of handling sick-leave negotiations has been suggested by others to enhance return to work, and should be further encouraged. However, specific effectiveness of this strategy is yet to be proven, and further investigation into the actual dealings between doctor and patients in these complex encounters is needed.

General practitioners' perceptions of working with the certification of sickness absences following changes in the Swedish social security system: a qualitative focus-group study

BACKGROUND

Many physicians in Sweden, as well as in other countries, find the matter of certification of sickness absence (COSA) particularly burdensome. The issuing of COSAs has also been perceived as a work-environment problem among physicians. Among general practitioners (GPs) are the highest proportion of physicians in Sweden who experience difficulties with COSA. Swedish authorities have created several initiatives, by changing the social security system, to improve the rehabilitation of people who are ill and decrease the number of days of sick leave used. The aim of this study was to describe how GPs in Sweden perceive their work with COSA after these changes.

METHODS

A descriptive design with a qualitative, inductive focus-group discussion (FGD) approach was used.

RESULTS

Four categories emerged from the analysis of FGDs with GPs in Sweden: 1) Physicians' difficulties in their professional role; 2) Collaboration with other professionals facilitates the COSA; 3) Physicians' approach in relation to the patient; 4) An easier COSA process.

CONCLUSIONS

Swedish GPs still perceived COSA to be a burdensome task. However, system changes in recent years have facilitated work related to COSA. Cooperation with other professionals on COSA was perceived positively.

Occupational health physicians have better work conditions for handling sickness certification compared with general practitioners: results from a nationwide survey in Sweden

AIMS

To study whether occupational health physicians (OPs) have a better work situation regarding handling of sickness certification compared with other physicians, in particular general practitioners (GPs), and to analyze associations between OPs' experiences of assessing and providing a long-term prognosis of patients' work capacity and some potentially interrelated factors.

METHODS

Answers to a nationwide survey from physicians who had sickness certification consultations at least once monthly were analyzed. Differences among OPs (n=481), GPs (n=4257) and physicians working in other clinical settings (n=9452) were estimated by chi square tests. Associations between OPs' experiences as above and potentially interrelated factors were estimated using logistic regression analyses.

RESULTS

Among OPs, a lower proportion experienced clinical work situations related to sickness certifications as 'very problematic', compared with the other physicians, and especially so compared with GPs. A higher proportion of OPs also had organizational support for handling sickness certifications. For OPs, experience of sickness certification consultations as problematic once a month or less often, not experiencing sickness certification tasks as a work environment problem, and having a well-established workplace policy regarding sickness certification matters were significantly positively associated with finding assessing and providing a long-term prognosis of work capacity as 'not at all/somewhat problematic'.

CONCLUSIONS

OPs' work situation regarding sickness certifications was favorable compared with that of other physicians, and especially compared with that of GPS. Our results underline the importance of organizational support for ensuring physicians' experience of having professional competence in handling assessments of patients' work capacity.

Predicting return to work among sickness-certified patients in general practice: properties of two assessment tools

AIM

The purpose was to analyse the properties of two models for the assessment of return to work after sickness certification, a manual one based on clinical judgement including non-measurable information ('gut feeling'), and a computer-based one.

STUDY POPULATION

All subjects aged 18 to 63 years, sickness-certified at a primary health care centre in Sweden during 8 months (n = 943), and followed up for 3 years.

METHODS

Baseline information included age, sex, occupational status, sickness certification diagnosis, full-time or part-time current sick-leave, and sick-leave days during the past year. Follow-up information included first and last day of each occurring sick spell. In the manual model all subjects were classified, based on baseline information and gut feeling, into a high-risk (n = 447) or a low-risk group (n = 496) regarding not returning to work when the present certificate expired. It was evaluated with a Cox's analysis, including time and return to work as dependent variables and risk group assignment as the independent variable, while in the computer-based model the baseline variables were entered as independent variables.

RESULTS

Concordance between actual return to work and return to work predicted by the analysis model was 73%-76% during the first 28-180 days in the manual model, and approximately 10% units higher in the computer-based model. Based on the latter, three nomograms were constructed providing detailed information on the probability of return to work.

CONCLUSION

The computer-based model had a higher precision and gave more detailed information than the manual model.

Variation in patients’ sick leave between general practitioner practices

Background: General practitioners (GPs) assess the existence of the patient’s disease, decide whether the disease affects the patient’s ability to work and if necessary, recommend sick leave. Our aim was to describe correlations in patients’ sick leave between GP practices (GPPs) in a 5-year period. Method: The study included 253 GPPs, from 2007 to 2011. The personal numbers of patients from each GPP were connected to DREAM, a registry at the Danish Ministry of Employment that includes social welfare payments, including sick leave benefits. We adjusted for patient age, gender, ethnicity and social differences. Spearman’s rank correlation coefficients (2007 – 2011) were used for calculating the correlation in adjusted sick leave. Results: The number of patient sick leave weeks between GPPs varied from 36 to 2,704 sick leave weeks per 1000 patients (18 – 65 years). The correlation coefficients for adjusted sick leave weeks varied from 0.90 to 0.94 ( P < 0.05). Correlations for the 10 GPPs with the highest number of sick leave weeks and the 10 GPPs with the lowest number of sick leave weeks were almost as high as the correlations of the total population of GPPs. Conclusions:The study showed great differences in sick leave between GPPs; however, significant correlation for adjusted sick leave in each GPP was demonstrated. This may indicate that GPs play an important role in their patients’ sick leave. The study provides a method to distinguish between GPPs with low patient sick leave and high patient sick leave in causal studies of sick leave differences among GPs.